Gossypiboma, the Hidden Enemy of an Emergency Cesarean Hysterectomy—Case Report and Review of the Literature

Gossypiboma or textiloma is a rare medical situation that can complicate the favorable evolution of a surgical case, with repercussions for the patient’s prognosis. The diagnosis can be difficult due to various clinical symptoms, the time elapsed since the surgical intervention, and the imaging often not being precise in detecting textilomas. Due to the medicolegal implications, the reporting of this event is inconsistent. We present a rare case of a 28-year-old woman who presented with vague pain in the left iliac fossa 11 months after an emergency cesarean hysterectomy was performed. The preoperative imaging examination identified the presence of a subhepatic mass with dimensions of 10 × 8 cm2 and another formation in the right iliac fossa with dimensions of 11 × 9 cm2. Exploratory laparotomy found the presence of a large subhepatic gossypiboma, intimately adherent to the hepatic angle of the colon and omentum and a second one adherent to the sigmoid colon, small intestine, and parietal peritoneum. The particularity of this case is given by the simultaneous presence of two textilomas with inconclusive evolution, which can make the differential diagnosis difficult to achieve. For a better assessment of the risk of occurrence of this pathology and the identification of a correct prevention strategy, we performed an extensive search and a review of all the articles published in the PubMed database, identifying 57 articles. In conclusion, emergency surgery increases the risk of this complication, and, as a result, prevention can be achieved by following existing protocols in the operating room.


Introduction
The medical terminology related to gossypiboma or textiloma defines the presence of an operating field, cotton compress, or surgical sponge left involuntarily in the peritoneal cavity during surgery [1].The most common localization of gossypibomas is the intraperitoneal cavity [1,2].Although the real incidence of gossypibomas is unknown, a positive evolution has been observed, marked by the decrease in detection rate in the last decades.Thus, if initially the reported incidence was 1:1000 abdominal surgeries [3], recent studies show 0.08-0.18:1000[4,5].The incidence regarding the identification rate of retained foreign bodies (RFB) related to the type of surgical intervention varies from 17.69% for cesarean section, 16.33% in abdominal hysterectomy, and 13.54% for exploratory laparotomy in the acute abdomen [6].Compared to the percentage of identification of gossypibomas from the total RFB, the incidence varies between 17% and 68% [4,5].Furthermore, Birolini et al., in a study of 4547 cases, identified a percentage of 90% of textilomas, of which the most common were large sponges [6].
The diagnosis can be early, a few days after the operation, or sometimes they can be identified after many years, and it can be associated with increased morbidity and sometimes mortality.Clinical manifestations, treatment, and prognosis of gossypibomas can vary depending on the time of diagnosis and the type and intensity of tissue reactions.Thus, early postoperative, acute, exudative, or purulent inflammatory reactions can occur, with the appearance of peritonitis and abscesses, in which the clinical signs of sepsis with fever, abdominal pain, nausea, vomiting, abdominal distention, and fatigue predominate.Late postoperatively, chronic inflammatory reactions, xanthogranulomatous, aseptic fibrosis, and calcifications can be encountered when patients can be asymptomatic or oligosymptomatic with abdominal pain, transit disorders for gases and stool, abdominal distension, or determined by the compression of the respective mass [7].
Imaging diagnosis is based on endovaginal/abdominal ultrasonography, abdominalpelvic radiological examination, contrast-enhanced computed tomography, and magnetic resonance imaging [8].The differential diagnosis must also be performed with other intraabdominal tumor masses [9].The therapeutic solution for these patients is, in most cases, surgical, this being all the more difficult the later the diagnosis is established.Complications caused by perforations, fistulizations, and obstructions require the intervention of a general surgeon in the surgical team due to intraoperative technical difficulties.
Although we accept that there is a risk of this undesirable medical situation occurring during surgical interventions due to the medicolegal implications, most surgeons (74%) mentioned that they did not inform the patient about the existence of a foreign body, invoking other possible causes of the indication for re-intervention [6].
This article aims to evaluate the magnitude and risk of gossypibomas after cesarean sections, especially emergency ones, to identify the risk factors and reduce their incidence.

Case Report
The 28-year-old patient presented to the Filantropia Obstetrics-Gynecology Clinical Hospital, Bucharest, with chronic lower abdominal pain, especially in the left iliac fossa.The patient had two cesarean sections in another hospital (in 2018 and 2021, respectively).The last one was performed 16 months ago for uterine rupture prophylaxis, followed by an emergency supracervical hysterectomy due to the formation of a pelvic hematoma.
The clinical symptoms were dominated by chronic pain in the left iliac fossa, which progressively increased in intensity.A well-defined tumor mass was palpated in the left lower abdomen during clinical examination.The bimanual pelvic examination revealed a tumor mass with dimensions of 11 × 9 cm 2 , increased consistency, and reduced mobility, which was slightly painful.Blood count, liver, and kidney function tests were within normal limits.The ultrasound examination (Figure 1a-c) reveals a surgically excluded uterus with a 2.9 cm long cervix, 3.5 × 2.8 cm 2 right ovary; the left ovary is not visible, instead a complex mass is identified in the left lower quadrant (left iliac fossa) with dimensions of 9.6 × 5.4 × 4.8 cm 3 , with hyperechoic areas alternating with anechoic areas, without highlighting a capsule, without Doppler signal.A mass with the same characteristics with dimensions of 8.5 × 4.9 cm 2 was identified in the upper right quadrant.The MRI (Figure 1d,e) reveals expansive formations, ovarian on the left side and paracaval in the mid-paramedian abdominal floor on the right side, with an appearance suggestive of endometriosis cysts.
adhered to the level of the ascending colon.In the left iliac fossa, a tumor mass of approximately 12 × 10 cm is present, to which the parietal peritoneum, descending colon, sigmoid colon, and intestinal loops are adherent.It was completely removed en bloc with the omentum, left ovary, and fallopian tube.The second tumor mass of approximately 10 × 9 cm in the upper right abdominal quadrant was intimately adherent to the anterior parietal, peritoneum, the ileal loops, and the hepatic angle of the colon.The sectioning of the first formation with dimensions of 9.5 × 9.5 × 6.5 cm identified a gauze mesh (Figure 2), which was resected with a portion of the omentum.The postoperative evolution was without complications, with the patient being discharged on the fifth postoperative day.Elective exploratory laparotomy identified the presence of the two encapsulated masses adherent to the neighboring structures.During the inspection of the peritoneal cavity, adhesions of the omentum at the level of the anterior parietal wall are observed, as well as a surgically absent uterus, the appendix with right fallopian tube, and the ovary adhered to the level of the ascending colon.In the left iliac fossa, a tumor mass of approximately 12 × 10 cm 2 is present, to which the parietal peritoneum, descending colon, sigmoid colon, and intestinal loops are adherent.It was completely removed en bloc with the omentum, left ovary, and fallopian tube.The second tumor mass of approximately 10 × 9 cm 2 in the upper right abdominal quadrant was intimately adherent to the anterior parietal, peritoneum, the ileal loops, and the hepatic angle of the colon.
The sectioning of the first formation with dimensions of 9.5 × 9.5 × 6.5 cm 3 identified a gauze mesh (Figure 2), which was resected with a portion of the omentum.The postoperative evolution was without complications, with the patient being discharged on the fifth postoperative day.
The macroscopic examination revealed: -Left adnexal tumor mass measuring 9.5 × 9.5 × 6.5 cm 3 ; when sectioning, textile material with dimensions of 9 × 8 × 5 cm 3 is evacuated; after the extraction of the textile material, the internal surface of the pseudocyst wall is intensely congestive, with greyish-yellow deposits; and isolated intramural nodular mass with dimensions of 4.5 × 4.5 × 1 cm 3 of firm elastic consistency; -Subhepatic tumor mass with dimensions of 10 × 8 × 5.5 cm 3 with a grayish-pink external surface with areas of fatty tissue; when sectioning, textile material with dimensions of 7 × 6 × 4 cm 3 is extracted.
The microscopic examination highlighted: -Left adnexal tumor mass: tissue fragment with a histopathological aspect of conjunctiveadipose and vascular-nervous tissue presenting multiple foci of chronic granulomatous inflammation with multinucleated foreign body giant cells arranged around exogenous, acellular, translucent materials; diffuse areas of fibroblast-fibrocystic proliferation; numerous groups of foamy histiocytes, some with a multinucleolate appearance; and marked capillary hyperemia, interstitial edema, and diffuse regions of hematic extravasation.The ovarian histological structure is identified at a certain level, with multiple foci of chronic granulomatous inflammation with foreign body multinucleated giant cells, in addition to tubal wall with lesions of chronic xanthogranulomatous salpingitis, discrete tubular epithelial hyperplasia, moderate capillary hyperemia, and intramural interstitial edema; -Right subhepatic tumor mass: tissue fragment with a histopathological aspect of conjunctive-adipose and vascular-nervous tissue presenting multiple foci of chronic granulomatous inflammation with multinucleated foreign body giant cells arranged around exogenous, acellular, translucent materials; diffuse areas of fibroblast-fibrocystic proliferation; numerous groups of foamy histiocytes, some with a multinucleolate appearance; and moderate capillary hyperemia, interstitial edema (Figure 3).The macroscopic examination revealed: -Left adnexal tumor mass measuring 9.5 × 9.5 × 6.5 cm; when sectioning,

Discussion
Gossypiboma or textiloma represents an important medical event due to the medicolegal implications and an increased risk of morbidity and mortality [1] Furthermore, the actual reporting of these cases is inconstant, with the global incidence reported in abdominal surgeries being between 1 and 1.2 per 1000-1500 [9].Another study carried out on 49,831 surgeries under general anesthesia identified 24 cases of retained foreign bodies (0.48:1000), of which 17% (4 cases-0.08:1000)were gossypiboma [5].It has been observed that the increased incidence is associated with emergency surgical interventions, especially those in the obstetric field (placenta previa, placenta accreta hemorrhage, uterine rupture).Emergency surgical interventions represent the most frequently encountered risk factor regarding the appearance of gossypibomas (26%) followed by wrong counting of sponges (25%) [6].The mechanisms underlying the increase in risk are non-compliance with operating protocols, lack of coordination of the surgical team, lack of training of the medical staff, modification of the initial operating plan through the participation of a multidisciplinary team, improper counting of the textile material due to increased blood loss, long operations and laborious, intraoperative instability of the patient, increased BMI, and comorbidities [9].
We performed a comprehensive electronic search in the PubMed database, the search was from inception to 31 May 2023, where we identified 57 published cases with the MeSH search terms "gossypiboma", "textiloma", "gauze", "sponge", and "cesarean section" (Table 1).

Discussion
Gossypiboma or textiloma represents an important medical event due to the medicolegal implications and an increased risk of morbidity and mortality [1].Furthermore, the actual reporting of these cases is inconstant, with the global incidence reported in abdominal surgeries being between 1 and 1.2 per 1000-1500 [9].Another study carried out on 49,831 surgeries under general anesthesia identified 24 cases of retained foreign bodies (0.48:1000), of which 17% (4 cases-0.08:1000)were gossypiboma [5].It has been observed that the increased incidence is associated with emergency surgical interventions, especially those in the obstetric field (placenta previa, placenta accreta, hemorrhage, uterine rupture).Emergency surgical interventions represent the most frequently encountered risk factor regarding the appearance of gossypibomas (26%), followed by wrong counting of sponges (25%) [6].The mechanisms underlying the increase in risk are non-compliance with operating protocols, lack of coordination of the surgical team, lack of training of the medical staff, modification of the initial operating plan through the participation of a multidisciplinary team, improper counting of the textile material due to increased blood loss, long operations and laborious, intraoperative instability of the patient, increased BMI, and comorbidities [9].
We performed a comprehensive electronic search in the PubMed database, the search was from inception to 31 May 2023, where we identified 57 published cases with the MeSH search terms "gossypiboma", "textiloma", "gauze", "sponge", and "cesarean section" (Table 1).
The average duration from cesarean section to the time of diagnosis of gossypibomas was, on average, (±SD) 3.69 ± 6.24 years (range from 0.04 to 29 years), which indicates that in most cases, the clinical manifestations have been asymptomatic or oligosymptomatic.This is also highlighted in the study by Birolini et al., in which asymptomatic and oligosymptomatic clinical manifestations represented 12% and 71% of cases, respectively [6].The average age of the patients from all the studied cases at the time of diagnosis was 34.58 ± 8.38 (range from 20 to 68 years), representing an independent factor of the incidence of gossypibomas.
Although a series of studies showed an increased rate regarding the time of diagnosis of gossypiboma being within the first two months, the analysis of the articles studied in this review highlighted a rate of 19.29%, with a peak of 47.36% at more than a year after the surgery.This fact is possibly correlated with the intensity of the clinical manifestations, the severe ones being found in only 17% of cases [6].The body's response to the intraabdominal presence of textile material, depending on the time elapsed until the diagnosis is established, is based on the appearance of an aseptic process of a fibrinous nature or a local exudative process that allows the formation of an abscess [7].The therapeutic strategy of gossypiboma is surgical, being differentiated depending on the diagnosis time and possible complications' association.Thus, the preoperative evaluation and preparation of these cases are essential, because the association of a fistula, an occlusion, a perforation, an abscess, or an extensive adhesion syndrome involving neighboring organs can be elements that complicate the surgical intervention, and prolong operative time and the duration of hospitalization.The surgical approach can be on the same incision by open, endoscopic, laparoscopic, or robotic surgery.
Late diagnosis of gossypiboma due to the intense inflammatory and granulomatous reaction with the textile material forms an important adhesive process.Early diagnosis is associated with peritonitis, requiring a quick approach to remove the textiloma.Depending on the topography of the textiloma, and the complications of its presence (fistulas, perforations), its surgical removal may involve intestinal resections and anastomoses, as well as epiploic, hepatic, gastric, and adnexal resections [1,11].
The basic prevention related to the occurrence of gossypiboma is achieved by managing the number of pieces of soft textile material and careful exploration by the surgical team of the peritoneal cavity before closing the wound.Using textile material with radiopaque thread or chips can contribute to their rapid identification [7,51] (Figure 4).

Conclusions
Although it represents a rare postoperative complication, gossypiboma is associated with a morbidity and mortality rate dependent on the initial pathology, the delay in establishing the diagnosis, and the subsequent postoperative evolution with serious

Conclusions
Although it represents a rare postoperative complication, gossypiboma is associated with a morbidity and mortality rate dependent on the initial pathology, the delay in establishing the diagnosis, and the subsequent postoperative evolution with serious ethical and medicolegal implications.The non-specific clinical manifestations, the imaging that is difficult to interpret, the unpredictable evolution burdened with complications, and the multidisciplinary approach are all challenges regarding the therapeutic management of gossypiboma.As a result, prevention is the best treatment for this pathology, achieved by following the surgical and the operating room protocols, managing the operative time appropriate to the surgical intervention's complexity, and ensuring the training level of the medical staff.In the situation where we encounter this pathology, the surgical solution of the case and the professional deontology in relation to colleagues and patients are elements that contribute to an appropriate approach.

Figure 1 .
Figure 1.(a) Ultrasound longitudinal and (b) transversal section of a complex mass with hyperechoic alternating with anechoic areas identified in the left lower quadrant (left iliac fossa), (c) ultrasound scan shows an echogenic, inhomogeneous mass with dense posterior acoustic shadowing located in the right upper abdominal quadrant, subhepatic, (d) MRI axial T1WI section shows a round mass of hypo intensity in the right upper abdominal cavity (white arrows), (e) MRI T2WI-FS axial section shows heterogeneous hyperintensity with a complete hypo intensity capsule (white arrows).

Figure 1 .
Figure 1.(a) Ultrasound longitudinal and (b) transversal section of a complex mass with hyperechoic alternating with anechoic areas identified in the left lower quadrant (left iliac fossa), (c) ultrasound scan shows an echogenic, inhomogeneous mass with dense posterior acoustic shadowing located in the right upper abdominal quadrant, subhepatic, (d) MRI axial T1WI section shows a round mass of hypo intensity in the right upper abdominal cavity (white arrows), (e) MRI T2WI-FS axial section shows heterogeneous hyperintensity with a complete hypo intensity capsule (white arrows).

Figure 2 .
Figure 2. (a) Unfolded retained gauze towel resected from the lower left abdominal quadra (b) intraoperative imaging showing the gossypiboma adherent to the bowel with retaine seen inside; (c) postoperative imaging by sectioning the specimen identified a surgical gauze object retained in the mass; (d) postoperative view of both specimens discovered intra-abdo

Figure 2 .
Figure 2. (a) Unfolded retained gauze towel resected from the lower left abdominal quadrant mass; (b) intraoperative imaging showing the gossypiboma adherent to the bowel with retained gauze seen inside; (c) postoperative imaging by sectioning the specimen identified a surgical gauze foreign object retained in the mass; (d) postoperative view of both specimens discovered intra-abdominally.

Figure 3 .
Figure 3. Microscopic examination showed by H&E × 100 staining a fibrous encapsulation with multinucleated foreign body giant cell reaction (in the cartridge ×400 magnification).

Figure 3 .
Figure 3. Microscopic examination showed by H&E × 100 staining a fibrous encapsulation with multinucleated foreign body giant cell reaction (in the cartridge ×400 magnification).

Figure 4 .
Figure 4. Algorithm to prevent gossypiboma/retained instrument in emergency surgical interventions in Obstetrics.

Figure 4 .
Figure 4. Algorithm to prevent gossypiboma/retained instrument in emergency surgical interventions in Obstetrics.

Table 1 .
Synopsis of the gossypiboma all-time search in PubMed database.

Table 1 .
Synopsis of the gossypiboma all-time search in PubMed database.